Lousia Ovington independent investigation report ... - NHS North East

hours. They did not have access to the CMHT notes. In Louisa Ovington’s case, she
said, they were not made aware, for example, that she had been in hospital for 18
months on a Section 37. She also stated that the crisis resolution service had no
access to CPA information or risk assessments. Their own risk assessments tended
to be based purely on what limited information was available at the time, but were
updated subsequently. She said that the service was not equipped to deal with
personality disordered clients and she felt that dealing with someone like Louisa
Ovington was not, according their criteria at the time, appropriate.
Team Manager 2, who was in charge of the team, took a broader view of the function
of the CRT service. It was evident that he was concerned about the general mental
health service response to Louisa Ovington at this time. He also expressed his concern
about the lack of an overall agreed care plan, in view of the fact that Louisa Ovington
was coming into contact with criminal justice services as well as health services. He
told the panel “It felt like we couldn’t get a grip of the situation as an overall service.
I felt we were just kind of mirroring some of her behaviour in the presentation. Our
response was becoming chaotic as well”.
He felt that in the light of the number of referrals received in a very short period of
time they needed “an over-arching care plan” to ensure that they all had a shared
understanding of what her needs were and what their roles were within that. In
September 2004 Team Manager 2 urged multi agency action in relation to Louisa
Ovington and expressed his concern to Staff Grade Psychiatrist 1, Social Worker 7 and
others.
Team Manager 2 told the panel that Staff Grade Psychiatrist 1 responded to phone
calls from the crisis resolution service and made himself available for appointments,
within two to three days of a request. However, he commented that when you have a
doctor working with the crisis resolution service (as they sometimes had) it gives you a
“much, much better system”.
MAPPA 80
CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS
The issue of whether Louisa Ovington should have been referred to MAPPA is quite
confused. The terminology has changed somewhat; at that point in time the words
public protection/risk meeting seem to have been used interchangeably with MAPPA
and there is no clear idea about what the difference would have been between a ‘risk
meeting’ and a ‘multi-agency meeting’. What is clear is that Social Worker 7 was
concerned about Louisa Ovington’s risk to the public; that over a period of a week
or so she raised this matter with probation several times and that probation did not
accept that it was necessary to have a public protection/risk meeting - even after
Louisa Ovington had said that she may be driven to attack Mr Hilton. Probation
80 See Chapter 5 for an explanation of the MAPPA process
63